Methadone treatment in Germany: four years of nationwide regulation

by Peter Lang

In Germany a nationwide uniform regulation regarding the treatment of heroin addicts, called the "Neue Untersuchungs- und Behandlungsrichtlinien (NUB)" [New Examination and Treatment Guidelines], came into force after October 1991. As a result, insurance companies agreed to pay for methadone treatment and methadone became nationally available.

Before 1991, there was actually no methadone treatment. Within 6 months, by April 1992, about 1,000 heroin addicts were being treated with methadone and the number of persons in treatment increased linearly. By April 1994 about 9,700 people were being treated with methadone. By mid 1995 13,500 patients were actually in treatment. (Figures are based on regular surveys; NUB-treatments are notifiable.)

The number of heroin addicts in Germany is roughly estimated to be 120,000 to 150,000 persons. Nationwide, about 2,000 residential, drug-free oriented long-term therapy places are offered. The number of drug-related deaths increased dramatically from 1987 (441 deaths) to 1991 (2,125 deaths) but decreased after 1991 to 1,477 deaths in 1995. This is assumed to be related to methadone treatment. However, demographic changes, changes in drug use behaviour (decrease of heroin users), and a considerable increase of codeine treatment for heroin addicts (actual number in treatment is estimated to be 20,000 to 30,000) along with other factors may have significantly influenced this trend.

Indication for Methadone treatment

The relatively low number of patients in methadone treatment compared to the number given codeine is related to the fact that methadone treatment is restricted.

The restrictions limit the duration of treatment. Methadone distribution is carried out predominantly by panel doctors. Physicians require a treatment allowance and the conditions for an allowance differ between the states of Germany. Up until April 1995, 2,576 doctors were allowed to treat heroin addicts according to NUB-guidelines. The majority of the doctors are general practitioners. Addicts have to come daily to the practitioner to drink their methadone in a supervised setting. Take-home doses are an exception and only allowed under specific circumstances (a long treatment period without additional drug-use) and for a maximum of 3 days. Under very limited conditions, it is possible to start a methadone treatment outside NUB-guidelines, if the social welfare centres accept payment for the treatment. This is often restricted to special target groups of addicts (i.e. female prostitutes, addicts with long lasting drug-careers, prisoners). The estimated number of treatments financed by social welfare centres is 2,500.

In addition, the possibility to pay for one’s own methadone treatment exists (estimated number of paying addicts in Germany: about 2,000; costs per month 300-350 Deutschmarks [about 210-250 US-dollar].

Research Activities

So far, only a small number of research projects in Germany have been conducted concerning methadone treatment effects. Longitudinal studies, analysing treatment periods between 1990/91 and 1994, have been completed in the cities of Bremen and Hamburg. The final reports of both projects, published in 1995, are in agreement with each other to the effect that with methadone treatment one also achieves:

• an improvement of the health status of the addicts,

 

a clear decrease in heroin consumption and reduction of additional drug use,

 

a drop in criminal behaviour (i.e. drug dealing, larceny, prostitution).

Future Perspectives

Based on the results published up until now, it is obvious that an exclusion of heroin addicts from methadone treatment - forced by the restrictive NUB-guidelines in Germany - does not make any sense, because the beginning or continuation of an effective treatment modality is prevented.

Furthermore, it is known that psycho-social care is a necessary part of the methadone treatment regimen. But what "psycho-social care" precisely means, to what extent it is needed, and - primarily - who will pay for it, are relevant topics for discussion in Germany. An important step would be achieved if methadone would be accepted by the health insurance agencies as a possibility for the treatment of the heroin addiction itself. That would smooth the way to establishing an integrated methadone treatment programme in this country including medical, psycho-therapeutical and social measures.

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